From the Department of Radiology, Stanford University School of Medicine, 300 Pasteur Dr, Stanford, CA 94305-5105.
Radiographics. 2018 Oct;38(6):1705-1716. doi: 10.1148/rg.2018180040.
Radiology practices are increasingly implementing standardized report templates to overcome the drawbacks of individual templates. However, implementing a standardized structured reporting program is not necessarily straightforward. This article provides practical guidance for radiologists who wish to implement standardized structured reporting in their practice. Challenges that radiology groups encounter tend to fall into two categories: technical and organizational. Defining and carrying out technical work can be tedious but tends to be relatively straightforward, whereas overcoming organizational challenges often requires changes in individuals' strongly held values, beliefs, roles, and relationships. Established organizational change models can help frame the organizational strategy to implement a standardized structured reporting program. Once leadership support is secured, a standardized structured reporting committee can be convened to establish report priorities, standards, design principles, and guidelines. Report standards help to establish the common framework upon which all report templates are constructed, helping to ensure report consistency. By using these standards, committee members can create reports relevant to their subspecialties, which can then be edited for formatting and content. Once report templates have been developed, edited, and published, an abbreviated form of the same process can be used to maintain the reports, which can be accomplished with much less effort than that initially required to create the templates. After standardized structured report templates are implemented and become embedded in practice, most radiologists eventually appreciate the merits of the program. RSNA, 2018.
放射科实践越来越多地采用标准化报告模板,以克服个别模板的缺点。然而,实施标准化结构化报告程序并不一定简单。本文为希望在实践中实施标准化结构化报告的放射科医生提供实用指南。放射科小组遇到的挑战往往分为两类:技术和组织。定义和执行技术工作可能很乏味,但往往比较简单,而克服组织挑战通常需要改变个人强烈持有的价值观、信念、角色和关系。既定的组织变革模型可以帮助制定实施标准化结构化报告程序的组织策略。一旦获得领导层的支持,就可以召集一个标准化结构化报告委员会,确定报告优先级、标准、设计原则和指南。报告标准有助于建立所有报告模板构建的通用框架,有助于确保报告的一致性。通过使用这些标准,委员会成员可以创建与其亚专业相关的报告,然后可以对其进行格式和内容编辑。一旦开发、编辑和发布了报告模板,就可以使用相同的简化流程来维护报告,这比最初创建模板所需的工作量要小得多。在实施标准化结构化报告模板并将其嵌入实践后,大多数放射科医生最终会欣赏该程序的优点。RSNA,2018.